Sacred Earth Healing Arts
Reiki
Intake and Release Waiver Liability Form
Name:_____________________________________
Address:___________________________________
City:___________________ Postal Code:______________
Phone #:____________________________
Email: _______________________________Would you like to be on our email list? Yes / No
Date of Birth: _________________________
Emergency Contact:_______________________ Phone #:__________________
Are you currently under the care of a physician? Yes / No
How did you hear about us?________________________________________
Have you ever had a Reiki session before? Yes / No
Are you OK with gentle reiki touch? Yes / No
Are you comfortable with a guided meditation to begin your session? Yes / No
Circle any of these tools that you are comfortable with me using during your session: Circle
Essential oils Smudge/Incense Crystals Singing bowls
Pendulum Music Meditation techniques Reflexology Accupressure
What do you hope to accomplish with this Reiki/Healing session: Circle
Relaxation Stress reductions Pain Reductions More energy
Emotional/trauma Shifting habits Spiritual awareness
How would you rate your present state of health? Circle Excellent Good Fair Poor
Lifestyle: Circle Active Sedentary
Stress levels: Circle High Medium Low
Sleep pattern: Circle Good Average Poor
Ability to relax: Circle Good Average Poor
Do you have any additional questions and concerns before starting your session?
*I declare that the information I have given is correct and that as far I am aware I can undertake
treatment without any adverse effects.
*I acknowledge that Melissa Yarrow (Sacred Earth Healing Arts ) is a Reiki Practitioner, and is in
private practice for the purpose of providing mental/emotional/physical and spiritual support using
Reiki and other healing techniques. I also acknowledge that Melissa Yarrow is not a medical doctor or mental health care professional, and accordingly can not provide me with medical or psychological advice. I recognize that Reiki is only one factor in the management of my health. I recognize that Reiki is NOT a replacement therapy for any physical, or mental health issues and I should seek medical professionals for such aliments. I will rely on Melissa Yarrow only for the sharing of important skills and tools involved in increasing my mental/emotional/physical and spiritual awareness through the transfer of loving and compassionate energy. *Melissa Yarrow is a support person who has been attuned to provide Reiki treatments. She will respond to my inquiries by providing positive reinforcement and appropriate feedback. I acknowledge that it is my over all responsibility to advise Melissa Yarrow with my level of comfort or discomfort during my session. I acknowledge I am able to request to stop treatment at anytime. I acknowledge that I will share any other information which may influence her support of me before and during my session.
*In consideration of the services, information, and support I have received or will hereafter receive from Melissa Yarrow I hereby hold harmless Melissa Yarrow from any or all liability in consequence of such services, information and support given, and release and waive all claim for damage how so ever incurred or to be incurred, as a result of such services, information and support. This Release shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns. *I have read this Release prior to signing and I understand its effect. I am aware that by signing this Release I am waiving certain legal rights, which I or my heirs, next of kin, executors, administrators and assigns may other wise have had against Releasees.
___________________________________ Date
___________________________________ Printed Name
___________________________________ Signature
___________________________________ Melissa Yarrow, Master Usui Reiki Practitioner
